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Understanding Blood Calcium Levels

Mallorca (Majorca) is one of Spain's Islands in the Mediterranean. (Dr. Noorali Bharwani)
Mallorca (Majorca) is one of Spain's Islands in the Mediterranean. (Dr. Noorali Bharwani)

Calcium and vitamin D are the two most important nutrients for bone health. Calcium has many other important functions in the body.

Calcium is necessary for life.

In addition to building bones and keeping them healthy, calcium helps our blood clot, helps nerves send messages and helps muscles contract. About 99 percent of the calcium in our bodies is in bones and teeth.

Each day, we lose calcium through our skin, nails, hair, sweat, urine and feaces. But our bodies cannot produce new calcium. That is why it is important to get calcium from the food we eat. When we do not get enough calcium for our body’s needs, it is taken from our bones. This makes bones weak.

A natural source of calcium in our diet comes from milk and milk alternatives. It is important to drink milk everyday. Calcium is also found in dark leafy greens, legumes and canned salmon.

Role of parathyroid hormone

Excessive calcium (hypercalcemia) most commonly results from overactive parathyroid glands. These four tiny glands are each about the size of a grain of rice and are located on or near the thyroid gland. Certain types of cancer, other medical disorders, some medications, and excessive use of calcium and vitamin D supplements can also cause hypercalcemia.

Overactive parathyroid gland (hyperparathyroidism) can raise calcium levels. The role of the parathyroid hormone is to help maintain an appropriate balance of calcium in the bloodstream and in tissues that depend on calcium for proper function.

Hyperparathyroidism is often diagnosed before signs or symptoms of the disorder are apparent. When symptoms do occur it is because of damage or dysfunction in other organs due to high calcium levels in the blood, urine, or too little calcium in bones.

Hyperparathyroidism can cause a wide variety of symptoms. It can make bones fragile (osteoporosis), create kidney stones, increase urination, cause abdominal pain, weakness, depression and forgetfulness. It can also cause aches and pains, nausea, vomiting or loss of appetite.

When your calcium levels are low, your parathyroid glands secrete parathyroid hormone to restore the balance. Parathyroid hormone raises calcium levels by releasing calcium from your bones and increasing the amount of calcium absorbed from your small intestine. Parathyroid hormone also acts on the kidneys, resulting in decreased excretion of calcium.

The physiology and balancing acts of calcium, phosphorus, vitamin D and parathyroid hormone is very interesting and not easy to comprehend.

To summarize:

Bones play an important role in blood calcium levels, which must be maintained within narrow limits to maintain bodily functions.

Bones are the major storage site for calcium. The movement of calcium into and out of bone helps to maintain blood calcium levels.

Parathyroid hormone and calcitonin also help regulate blood calcium levels.

Parathyroid hormone promotes the absorption of calcium by the small intestines, which also increases blood calcium levels.

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Stroke Misdiagnosis in Young Adults on the Rise

Piazza dei Miracoli (English: Square of Miracles), formally known as Piazza del Duomo (English: Cathedral Square), is a walled 8.87-hectare area located in Pisa, Tuscany, Italy. (Dr. Noorali Bharwani)
Piazza dei Miracoli (English: Square of Miracles), formally known as Piazza del Duomo (English: Cathedral Square), is a walled 8.87-hectare area located in Pisa, Tuscany, Italy. (Dr. Noorali Bharwani)

A 2009 study by the Department of Neurology and Stroke Program at Wayne State University/Detroit Medical Center found that among 57 young stroke victims, one in seven were given a misdiagnosis of vertigo, migraine, alcohol intoxication, seizure, inner ear disorder or other problems – and sent home without proper treatment.

While the majority of strokes strike people over the age of 65, the incidence of strokes in individuals 50 and younger is on the rise. Because people associate stroke with the elderly, symptoms in younger victims can often be missed or dismissed – even by medical professionals.

What are the signs of stroke?

Recognizing the signs of stroke can be the first step to getting correct treatment. Experts recommend you use the mnemonic device FAST.

Face: is it drooping?

Arms: can you raise both arms?

Speech: is it slurred or jumbled?

Time is of the essence: to call 9-1-1 right away.

How can you be diagnosed and treated early?

For a good outcome early intervention and treatment is important.

A person has symptoms, the paramedics are called and the person is brought to the hospital. The ER physician does clinical examination and investigations and comes to a diagnosis. All this should not take more than one hour.

Once the diagnosis is made the standard of treatment is administration of medication called tPA (tissue plasminogen activator) intravenously. When tPA is promptly administered, it can save lives and reduce the long-term effects of stroke. It needs to be used within three hours of having a stroke.

According to Alberta Health Services, Alberta’s stroke treatment is now reported to be among the fastest in the world. Alberta’s quality improvement program cuts time for life saving drug treatment from 70 to 36 minutes. A similar effort in the United States saw average door-to-needle times in participating hospitals drop from 74 minutes to 59.

The accepted benchmark has been to treat patients within 60 minutes of their arrival at the hospital. The Grey Nuns Hospital in Edmonton currently holds the provincial record with the fastest door-to-needle time – six minutes.

The medication (tPA) was introduced 20 years ago. But the results are not perfect. Although tPA is successful in recanalyzing the blocked artery in up to 78 per cent of cases, this rate of success is dampened by a high rate of acute repeat occlusion leading to an ultimate rate of 33 per cent partial and 30 per cent full recanalization.

Doctors are working on newer methods to treat stroke patients. Now doctors are able to pull a clot from the brain of patients while they are having a stroke. It is called an endovascular procedure or a mechanical thrombectomy. The procedure should be done within six hours of acute stroke symptoms. The entire procedure takes about 10 minutes. This treatment is not available in all centers across Canada.

The message is clear. Whether the patient is young or old, for the best possible results, it is important to identify stroke symptoms and seek treatment immediately.

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Important Things to Know About CPR (Cardio-Pulmonary Resuscitation)

Sunrise at Haleakala Volcano Summit in Maui, Hawaii. (Dr. Noorali Bharwani)
Sunrise at Haleakala Volcano Summit in Maui, Hawaii. (Dr. Noorali Bharwani)

“Bystander CPR is the most important predictor of survival from cardiac arrest,” says an article in the Canadian Medical Association Journal (CMAJ January 9, 2017).

The article is titled “Five Things to Know About Cardio-pulmonary Resuscitation.” Here is the summary.

1. Chest compressions – importance of fast pushes

Chest compressions during CPR should be fast pushes. In adult patients with out-of-hospital cardiac arrest, a large multicentric study has shown patient survival to hospital discharge was highest when compressions were between 100 and 120 per minute.

2. During the use of a defibrillator – importance of peri-shock pauses

During cardiac arrest the heart needs to be shocked with a defibrillator. To do this chest compression has to stop for a brief moment. This is called peri-shock pauses. Peri-shock pauses should be limited to improve survival. High priority is given to minimizing interruptions for chest compressions. It is recommended that total pre-shock and post-shock pauses in chest compressions be as short as possible.

Studies have shown survival is higher for those patients who received pre-shock pauses of less than 10 seconds and total peri-shock pauses of less than 20 seconds during CPR. Peri-shock pauses should be minimized during CPR by performing compressions while the defibrillator is charging.

3. Interrupted or continuous CPR strategy?

Bystander CPR is the most important predictor of survival from cardiac arrest. Any interruptions in chest compressions are associated with reduced blood flow and worse survival.

For this reason, and because ventilation (mouth to mouthing breathing) is a difficult skill to acquire for those who are not health care professionals, the guideline update recommends that members of the public provide uninterrupted continuous chest compressions.

Trained rescuers should provide 30 chest compressions that are interrupted by no more than 10 seconds to provide two ventilations (mouth to mouth breathing).

4. Role of medications during cardiac arrest

Should we use vasopressin or epinephrine during resuscitation? The aim is to improve return of spontaneous circulation and improve survival.

Vasopressin is a hormone. Its two primary functions are to retain water in the body and to constrict blood vessels to raise blood pressure.

Epinephrine, also known as adrenaline, is a hormone. It plays an important role in the fight-or-flight response of the body by increasing blood flow to muscles, output of the heart, pupil dilation, and blood sugar. As a medication it is used to treat a number of conditions, including anaphylaxis, cardiac arrest, and superficial bleeding.

The CMAJ article says vasopressin offers no advantage over epinephrine in cardiac arrest.

There is limited evidence to suggest that vasopressin and epinephrine can improve return of spontaneous circulation. Because simplicity is important during resuscitation efforts, the guideline update specifically recommends that epinephrine be administered as soon as possible following onset of cardiac arrest.

5. Maintain patient’s temperature during cardiac arrest

A target temperature should be maintained in the post-cardiac arrest period.

All adult patients who are comatose with return of spontaneous circulation following cardiac arrest should receive targeted temperature management. The guideline update recommends selecting and achieving a single target temperature between 32°C and 36°C, which should be maintained constantly for at least 24 hours.

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Women with Breast Cancer Can Modify Their Lifestyle to Improve Prognosis

Sunrise at the World's Tallest Tepee, Medicine Hat, Alberta. (Dr. Noorali Bharwani)
Sunrise at the World's Tallest Tepee, Medicine Hat, Alberta. (Dr. Noorali Bharwani)

“Although more than 90 per cent of patients with breast cancer have early stage disease at diagnosis, about 25 per cent will eventually die of distant metastasis,” says an article in the Canadian Medical Association Journal (CMAJ February 21, 2017).

Women with breast cancer would like to improve their prognosis and live long. Making positive lifestyle changes can improve long-term prognosis and be psychologically beneficial, since the feeling of loss of control is one of the biggest challenges of a cancer diagnosis.

So which lifestyle changes can be recommended to patients in addition to standard breast cancer treatments?

The CMAJ article reviews the role of lifestyle factors, particularly weight management, exercise, diet, smoking, alcohol intake and vitamin supplementation, on the prognosis of patients with breast cancer. Here is the summary.

Weight management

Weight gain during or after breast cancer treatment increases the risk of recurrence and reduces survival, irrespective of baseline body mass index (BMI). Patients who are obese or overweight at breast cancer diagnosis have a poorer prognosis. So lose weight.

Physical activity

Physical activity can reduce breast cancer mortality by about 40 per cent and has the most powerful effect of any lifestyle factor on breast cancer outcomes. At least 150 minutes per week (about 30 minutes a day) of physical activity is recommended, but less than 13 per cent of patients with breast cancer attain this. So exercise more.

Diet

Western-style diets (high in processed grains, processed meats and red meat) and prudent diets (high in fruits, vegetables, whole grains and chicken) have similar rates of breast cancer recurrence. Diets rich in saturated fat, especially from high-fat dairy products, may be associated with increased breast cancer deaths. Soy products have not been found to increase breast cancer recurrence and may actually reduce it. Eat less and stop eating fatty food.

Smoking

Recent evidence has shown a strong association between a history of smoking and breast cancer mortality. Women who quit smoking after diagnosis of breast cancer have higher overall survival and possibly better breast cancer–specific survival. So quit smoking.

Alcohol intake

Findings are too inconsistent to conclude that alcohol consumption affects breast cancer outcomes. However, limiting alcohol consumption to one or fewer drinks per day reduces the risk of a second primary breast cancer.

Vitamin supplementation

Moderate increases in dietary vitamin C or oral supplementation may reduce breast cancer mortality, but randomized trials are needed to confirm these findings. Vitamin E supplementation is not associated with breast cancer outcomes. Low levels of vitamin D at diagnosis have been associated with an increased risk of breast cancer deaths. However, randomized trials are needed to determine whether supplementation improves prognosis. One multivitamin a day and Vitamin D 2000 units a day is good for your health.

So the message is clear – make positive life-style changes like exercise more, lose weight and eat healthy. And keep smiling.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!